First Name - Inland Marine



|Individual Applicant Information | Primary Applicant | Co-applicant |Date: |

|First Name |Middle Name |Last Name |Suffix |

|      |      |      |      |

|Social Security Number |Birth Date |Driver’s License No. |State | Unmarried |

| | | | |Married |

| | | | |Separated |

|      |      |      |      | |

|Home (check preferred contact) |Work Phone |Cell Phone |Email Address |

|(     )     –      |(     )     –      |(     )     –      |      |

| Own Rent|Street Address (No P.O. Boxes) |Apt. |

|Family |State | |

| |      |      |

|How Long? |City |State |Zip |County |

|      yrs |      |      |      |      |

|Previous Residence Address (if less than 5 yrs at current) |City |State |Zip Code |How Long? |

|      |      |      |      |      yrs |

|Employer |Title |Monthly Employment Income |

|      |      |Gross:       |Net:       |

|Street Address |City |State |Zip Code |How Long? |

|      |      |      |      |      yrs |

|Previous Employer (if less than 5 yrs at current) |City |State |Zip Code |How Long? |

|      |      |      |      |      yrs |

|Nearest Relative (not living with you) |Relationship |Street Address |City |State |Home Phone |

|      |      |      |      |      |      |

|Checking Acct. Bank Name |Savings Acct. Bank Name |Last boat financed with: |Monthly Payment |

|      |      |      |      |

|Mortgage / Landlord Name |Monthly Payment |Sources of Other Income (see * below) |Monthly Amount |

|      |      |      |      |

|Have you declared bankruptcy in the last 10 years? | Yes No |* Alimony, child support or separate maintenance income need not be revealed if you |

| | |do not wish to have it considered as a basis for repaying this obligation. |

|Have you ever had any property repossessed? | Yes No | |

|Authorization and Certification |Signature |

|The undersigned: (1) Makes all of the above representations, which are certified correct, for the purpose of securing |X |

|credit; (2) Authorizes Inland Marine and any prospective lender to gather whatever credit information and employment | |

|history is considers necessary and obtain credit reports periodically; (3) Authorizes Inland Marine to use and share | |

|information with other entities that are related to it by common ownership or control; (4) Understands that Inland | |

|Marine will retain this application whether or not it is approved, and that it is the applicant’s responsibility to | |

|notify the creditor of any changes of name, address, or employment; and, (5) Authorizes Inland Marine to share this | |

|information with an Marine Insurance Agency if an insurance quote is requested below. | |

|Boat Information (complete on “primary application”) |

|Boat |Year |Make |Model |Length |Hull ID |

| New |      |      |      |      |      |

|Used | | | | | |

|Motor(s) |Year |Make |Model |HP |Type |

| New |      |      |      |      | Inboard I/O Outboard |

|Used | | | | | |

|Fuel |Serial Number Motor 1 |Serial Number Motor 2 |Seller |

| Gas |      |      | Private Broker Dealer |

|Diesel | | | |

| | | |Name(s) |

|Sale |Registration and Titling |      |

|Agreed Sale Price |$      |Boat will be registered in the state of: | |

| | |      |Address |

|Sales Tax (+) |$      | |      |

| | |Current registration or Documentation #: | |

|Title/Registration Fees (+) |$      |      |City, State, Zip |

|SUB-TOTAL = |$      | |      |

| | |Is there a Lien? Yes No if yes, then: | |

|Down Payment (-) |$      |Amount |$      |Day Phone       |

| | |Bank |      | |

|AMOUNT REQUESTED |$      |Acct # |      |Evening Phone       |

| | |Phone |      | |

|Please provide a no obligation Insurance Quote: | Yes No | | |

INLAND MARINE 1600 W. 10TH ST ANTIOCH, CA 94509 PH:925-757-1714 FAX 925-757-1729 WWW.INLAND-

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